Description
Core Elements, Key Characteristics, and Procedures
Resource requirements
Recruitment
Policies and Standards
Quality Assurance
Monitoring and Evaluation
Key Articles and Resources
References

Description

Comprehensive Risk Counseling and Services (CRCS), formerly Prevention Case Management (PCM), is a client-centered HIV prevention activity that provides intensive, ongoing, individualized prevention counseling, support, and service brokerage. Priority for CRCS services should be given to persons at very high risk for HIV. Originally, CRCS was conceived as a combination of HIV risk-reduction counseling and conventional case management for persons at high risk of transmitting or acquiring HIV. However, information from CRCS demonstration projects indicates that a more successful model for CRCS clearly defines the CRCS prevention counselor’s primary role as working closely with other referral providers to assist clients whose psychosocial needs are a barrier to their risk-reduction goals. Often case management services and benefits are not available, especially for persons who are HIV-negative or who do not know their status. Therefore, the prevention counselor is encouraged to provide traditional case management service such as linkage to services that may be available (for example, mental health or substance abuse services).

Goal
The fundamental goal of CRCS is promoting the adoption and maintenance of HIV risk-reduction behaviors by clients who have multiple, complex problems and risk-reduction needs.^1,2

How It Works
CRCS provides several sessions of client-centered HIV risk-reduction counseling. It helps clients initiate and maintain behavior change toward HIV prevention while addressing competing needs that may make HIV prevention a lower priority. CRCS addresses the relationship between HIV risk and other issues such as substance abuse, mental health, social and cultural factors, and physical health.

CRCS prevention activities might include conventional risk-reduction objectives such as

• decreasing the number of sex partners and needle-sharing partners
• increasing condom use
• abstinence
• referral to needed psychological, social, and medical services affecting risk behavior (e.g., treatment for mental health and substance abuse, diagnosis and treatment of sexually transmitted diseases)

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Core Elements, Key characteristics, and Procedures

Core Elements
Core elements are those parts of an intervention that must be done and cannot be changed. Core elements are essential and cannot be ignored, added to, or changed.

CRCS for Uninfected Persons at Very High Risk for HIV has the following 6 core elements:

• Provide CRCS as a combination of intensive, client-centered HIV risk-reduction counseling and linkage to other services that may be needed by clients in order to support or even make risk reduction possible.
• Base CRCS services on the premise that some people may not be able to prioritize HIV prevention when they perceive other problems to be more important and immediate.
• Consider persons whose HIV status is negative or unknown to be eligible if they have a recent history (past 6 months) of 1 or more of the following:
• unprotected sex with a person who is living with HIV
• unprotected sex in exchange for money or sex
• multiple (e.g., more than 5) or anonymous sex partners
• multiple or anonymous needle-sharing partners
• a diagnosis of a sexually transmitted disease
• Recruit persons who expressed some degree of commitment to participating in ongoing risk-reduction counseling.
• Hire prevention counselors with the appropriate training and skills to complete the CRCS activities within their job description.
• Develop clear procedures and protocol manuals for the CRCS program to ensure effective delivery of CRCS services and minimum standards of care.  For examples and assistance, see the CRCS Implementation Manual.

Key Characteristics

Key characteristics are those parts of an intervention (activities and delivery methods) that can be adapted to meet the needs of the CBO or target population.

CRCS for Uninfected Persons at Very High Risk for HIV has the following seven key characteristics:

• Develop a client recruitment and engagement strategy.
• Identify clients who are at highest risk and appropriate for CRCS (screening and assessment).
• Develop a written, client-centered prevention plan.
• Provide multiple HIV risk-reduction counseling sessions.
• Actively coordinate services with follow-up.
• Monitor and reassess clients’ needs, risks, and progress and revise prevention plans accordingly.
• Discharge clients from CRCS once they attain and maintain their risk-reduction goals. Agencies should establish protocols to classify clients as “active,” “inactive,” or “discharged,” and outline the minimum active effort required to retain clients.

Procedures
Procedures are detailed descriptions of some of the above-listed elements and characteristics and what makes them work.

Procedures for CRCS for Uninfected Persons at Very High Risk for HIV are as follows:

Recruitment and Engagement
Providers should ensure that clients understand the reason for a referral to CRCS, the role of the CRCS program, and the role of the CRCS provider. The CRCS prevention counselor or other designated recruitment specialist should work with the client to obtain written, informed consent describing all relevant policies and procedures (including the confidential and voluntary nature of the service) and indicating their commitment to participate in ongoing risk-reduction counseling. Clients should be given a copy of this consent form, and the original should be maintained in the client’s record. Each client should have an individual confidential record, and all records should be kept in a locked file cabinet; access should be limited to the prevention counselor and his or her immediate supervisor.

From the beginning, CRCS providers should develop a personal and working relationship with clients. This process, also known as engagement, may help clients feel comfortable discussing their behaviors. However, given the psychosocial challenges in the lives of CRCS clients, some potential clients may stay on the fringes of the program for some time before being ready to become fully engaged in CRCS. CBOs that provide CRCS should prepare for this by developing other engagement strategies, such as referring these clients to client support groups. In such groups, clients often develop more interest in discussing risk issues over time and, thus, their willingness to commit to CRCS may increase.

Eligibility Screening and Initial Assessment
All clients must be screened for eligibility for services. Appropriate screening procedures should be developed to identify persons at highest risk for acquiring HIV or other infections. The initial assessment should address transmission risks for HIV and other sexually transmitted diseases; substance use or abuse; and medical, psychological, and social needs. The client contacts should be conducted in a culturally appropriate manner.

Developing a Prevention Plan
After completing the initial assessment, the CRCS provider and the client should begin to develop a prevention plan and sign it. The prevention plan is a work in progress, probably will not initially define all of a client’s prevention needs, and is subject to modification throughout the client’s enrollment in CRCS. In fact, CRCS is most successful when the client focuses on a small number of goals at one time. CRCS providers should coordinate with other service providers, whenever possible, to provide the best possible constellation of services needed by each client. The initial plan should

• outline and define 1 or 2 risk-reduction behavioral goals and strategies for behavior change, including appropriate and SMART objectives. SMART stands for
• Specific
• Measureable
• Achievable
• Realistic
• Time-phased
• include referral to appropriate medical care, if needed, and referral for evaluation and treatment of sexually transmitted diseases, tuberculosis, hepatitis, and other related health concerns
• address referral for substance abuse treatment or mental health services, if needed
• include objectives related to counseling and testing, as needed, for clients whose HIV status is negative or unknown
• outline plans for referral follow-up

Delivering Counseling Sessions
Although some risk-reduction discussions can begin as soon as the CRCS counselor contacts a client, the CRCS counselor will intensify CRCS session when risk behaviors have been identified and appropriate risk-reduction strategies have been outlined. Counseling sessions are aimed at meeting the identified behavioral objectives. These sessions may include education, skill development, role-playing, support, or other techniques. HIV risk-reduction counseling is theory-based interactive counseling, skills building, support, and crisis management to facilitate the client’s adoption and maintenance of HIV risk-reduction behaviors.  Discussions should focus on risks associated with HIV acquisition and transmission or acquisition of other sexually transmitted diseases, negotiating safer sex, barriers that prevent clients from reaching their goals or objectives, perceived risk and vulnerabilities, economic and social needs, and utilization of medical, mental health, and drug/alcohol treatment programs.  Prevention counselors could use their own theory-based materials or use materials from existing interventions focused on one-on-one prevention counseling such as the CLEAR intervention which is one of CDC’s DEBIs.

Case notes should be filed after each session with a client indicating, at a minimum, the following:

• The goal and objective(s) addressed during the session, with specific steps agreed upon to accomplish each objective. Remember that small steps are often more realistic and, once accomplished, can lead to larger steps.
• Progress toward the goal. Remember to reward even small accomplishments.
• Barriers to behavior change and the way these are being or will be addressed
• Review of risk-reduction objectives and any needed modifications
• Referrals made, with plans for follow-up
• A plan for the next session

Coordinating Services
To avoid duplication of services, CRCS providers should ensure active coordination of services with follow-up. Prevention counselors should not provide case management services to the extent that they are already provided by existing case management systems. If referrals are a part of the prevention plan, the CBO should have a standardized written referral process, and a system should be in place to ensure availability and access to these referral services and to track their completion. This system might include agreements, such as memoranda of agreement with relevant service providers. Before communication between agencies begins, written informed consent for sharing client information should be obtained from the client. Medical and psychological services should be available in case of emergencies, and referral agreements for these services should be in place before initiating CRCS. Current referral and access information for all community providers should be maintained.

Following Up
Ongoing needs assessment is essential for monitoring progress toward CRCS goals and monitoring changing needs of the client. Prevention plans must be updated to reflect any change. After the client is able to maintain risk-reduction behaviors, the client and the CRCS prevention counselor, in consultation with clients, determine whether the client is ready for discharge from CRCS. CBOs implementing CRCS must have discharge protocols in place to ensure that discharged clients are connected to needed services and resources and that they are able to return to CRCS, if needed.

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Resource Requirements

People
CRCS needs staff members who are familiar and comfortable with the client base. Prevention counselors have commented that prior work experience in HIV services helped them with the delivery of CRCS. In addition to training on CRCS (e.g., training in helping clients set goals and objectives and particularly on risk-reduction counseling). In addition to training on CRCS and particularly on risk-reduction counseling, CRCS staff members should have worked with or at least know how to recognize people with mental health issues and make referrals to licensed counselors or mental health providers. Additional mental health background is a bonus but not a requirement for being a CRCS prevention counselor.  In addition, the number of staff members for CRCS depends on the number of clients that a CBO expects to serve, the needs of those clients, and what other services are offered in the area and by the agency. A typical caseload will include no more than 20 clients for each full-time (or equivalent) CRCS provider.

In areas with limited referral services, CRCS providers will need to meet a wide range of client needs themselves; thus, they may need to reduce the number of clients that they can see. In areas with ample referral services, CRCS providers will be able to refer more clients and carry a higher caseload, with which they can concentrate on their clients’ risk- reduction needs.

Space
CRCS needs a location that is

• easy to get to using public transportation
• private and secure, so that confidentiality can be maintained
• quiet and without interruptions (such as people entering and exiting the room or outside noise)
• close to other services that CRCS clients are accessing

Providers may need to meet clients outside of an office setting. When they do, efforts should be made to secure a location that will assure the confidentiality and safety of the client and CRCS counselor and minimize distractions and interruptions. Regardless of where actual CRCS sessions occur, the CBO implementing the intervention must ensure that all records are maintained securely in accordance with the agency’s policy for protecting client confidentiality. In addition, agencies need to develop protocols to assure safety of clients and staff at all times.

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Recruitment

CRCS programs rely on referrals and recruitment to establish a client base. To recruit clients for CRCS, programs are often more successful at recruiting clients when they are located in an agency or community setting that offers other services (e.g., outreach, counseling and testing services, medical care, assessment and treatment of sexually transmitted diseases, substance abuse treatment, and mental health services) for the target population. In this way, clients can be referred to CRCS from existing services. If these services are not offered on site, referral agreements from agencies providing these services should be established. Incentives (for example, bus tokens, hygiene kits, t-shirts) can be used to increase participation.

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Policies and Standards

Before a CBO attempts to implement CRCS, the following policies and standards should be in place to protect clients, the CBO, and the prevention counselor:

Confidentiality
A system must be in place to ensure that confidentiality is maintained for all participants in the program. Before sharing any information with another agency to which a client is referred, informed consent signed by the client or his or her legal guardian must be obtained.

Cultural Competence
CBOs must strive to offer culturally competent services by being aware of the demographic, cultural, and epidemiologic profile of their communities. CBOs should hire, promote, and train all staff to be representative of and sensitive to these different cultures. In addition, they should offer materials and services in the preferred language of clients, if possible, or make translation available, if appropriate. CBOs should facilitate community and client involvement in designing and implementing prevention services to ensure that important cultural issues are incorporated. The Office of Minority Health of the Department of Health and Human Services has published the National Standards for Culturally and Linguistically Appropriate Services in Health Care, which should be used as a guide for ensuring cultural competence in programs and services. (Please see Ensuring Cultural Competence in the Introduction of this document for standards for developing culturally and linguistically competent programs and services.)

Data Security
To ensure data security and client confidentiality, data must be collected and reported according to CDC requirements.

Informed Consent
CBOs must have a consent form that carefully and clearly explains (in appropriate language) the CBO’s responsibility and the clients’ rights. Individual state laws apply to consent procedures for minors; but at a minimum, consent should be obtained from each client and, if appropriate, a legal guardian if the client is a minor or unable to give legal consent. Participation must always be voluntary, and documentation of this informed consent must be maintained in the client’s record.

Legal and Ethical Policies
CBOs must know their state laws regarding disclosure of HIV status to sex partners and needle-sharing partners; CBOs are obligated to inform clients of the organization’s responsibilities if a CRCS client receives a positive HIV test result and the organization’s potential duty to warn. CBOs also must inform clients about state laws regarding the reporting of domestic violence, child abuse, sexual abuse of minors, and elder abuse.

Referrals
CBOs must be prepared to refer clients as needed. For clients who need additional assistance with decreasing risk behavior, providers must know about referral sources for prevention interventions and counseling, such as partner counseling and referral services and other health department and CBO prevention programs. All persons screened for CRCS, regardless of eligibility, should be referred to services relevant to their needs.

Volunteers
If the CBO uses volunteers to assist with or conduct this intervention, then the CBO should know and disclose how their liability insurance and worker’s compensation applies to volunteers. CBOs must ensure that volunteers also receive the same training and are held to the same performance standards as employees. All training should be documented. CBOs must also ensure that volunteers sign and adhere to a confidentiality statement.

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Quality Assurance

The following quality assurance activities should be in place when implementing CRCS:

Providers
Experience and Supervision
Supervisors of CRCS services might find it helpful to have experience working in the fields such as mental health and substance abuse services (e.g., licensed counselors or mental health providers) and HIV prevention, although experience working with the target population is also helpful. CRCS providers should meet at least monthly with either a direct supervisor or with a peer supervisor. Supervisors, other management personnel, and those providing CRCS services directly to clients are strongly encouraged to participate in appropriate trainings that cover the foundations of CRCS as well as the specific CRCS approach used by the agency in which they work. Training resources can be accessed by contacting your CDC Project Officer or state health department. 

Session Review
CBOs should have in place a mechanism to ensure that all sessions address the prevention plan, either by focusing on risk reduction specifically or on contextual issues that are related to risk behavior. Quality assurance activities can include observation and review of sessions by key staff and supervisors involved with the activity.

Record Review
Selected intervention record reviews should focus on assuring that consent forms (signed either by the client, if older than 18 or emancipated, or by a legal guardian) are included for all participants and that session notes are of sufficient detail to assure that clients are participating actively.

Clients
Clients' satisfaction with the services and their comfort should be assessed periodically. Process monitoring systems should also track the number of sessions each client attends, as well as reasons for not attending.

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Monitoring and Evaluation

Specific guidance on the collection and reporting of program information, client-level data, and the program performance indicators will be distributed to agencies after notification of award.

General monitoring and evaluation reporting requirements for the programs listed in the procedural guidance will include the collection of standardized process and outcome measures.  Specific data reporting requirements will be provided to agencies after notification of award. For their convenience, grantees may utilize PEMS software for data management and reporting.  PEMS is a national data reporting system that includes a standardized set of HIV prevention data variables, web-based software for data entry and management. CDC will also provide data collection and evaluation guidance and training and PEMS implementation support services.

Funded agencies will be required to enter, manage, and submit data to CDC by using PEMS or other software that transmits data to CDC according to data requirements.  Furthermore, agencies may be requested to collaborate with CDC in the implementation of special studies designed to assess the effect of HIV prevention activities on at-risk populations.

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Key Articles and Resources

Bauserman RL, Richardson D, Ward M, et al. HIV prevention with jail and prison inmates: Maryland's prevention case management program. AIDS Education and Prevention. 2003;15(5): 465–480.

Begley CE, Fourney A, Elreda D, Teleki A. Evaluating outcomes of HIV prevention programs: lessons learned from Houston, Texas. AIDS Education and Prevention. 2002;14(5):432–443.

Bolu OO, Lindsey C, Kamb ML, et al. Is HIV/sexually transmitted disease prevention counseling effective among vulnerable populations? A subset analysis of data collected for a randomized, controlled trial evaluating counseling efficacy (Project RESPECT). Sexually Transmitted Diseases.2004; 1(8):469–474.

CDC, Health Resources and Services Administration, National Institute on Drug Abuse, and Substance Abuse and Mental Health Services Administration. HIV Prevention Bulletin: Medical Advice for Persons Who Inject Illicit Drugs. Atlanta, Ga. and Rockville, Md: US Department of Health and Human Services; 1997.

Celantano DD, Dilorio C, Hartwell T, et al. Predictors of sexual behavior patterns over one year among persons at high risk for HIV. Archives of Sexual Behavior. 2002;31:165–176.

Falck R, Carlson RG, Price SK, Turner JA. Case management to enhance HIV risk reduction among users of injection drugs and crack cocaine. Journal of Case Management. 1994;3(4):162–166.

Kelly JA. Changing HIV Risk Behavior: Practical Strategies. New York: Guilford Press; 1995. 

Mejta CL, Bokos PJ, Mickenberg JH, Maslar ME, Senay E. Improving substance abuse treatment access and retention using a case management approach. Journal of Drug Issues. 1997; 27:329–340.

Prochaska, JO, DiClemente CC. Stages of change in the modification of problem behaviors. In: Hersen M, Miller PM, Eisler R eds. Progress in Behavior Modification. Thousand Oaks, CA: Sage; 1992;28:184–218.

Purcell DW, DeGroff AS, Wolitski RJ. HIV prevention case management: current practices and future directions. Health and Social Work. 1998;23:282–289.

Roffman RA, Stephens RS, Curtin L., et al. Relapse prevention as an intervention model for HIV risk reduction in gay and bisexual men. AIDS Education and Prevention. 1998;10:1–18.

San Francisco Department of Public Health. HIV prevention case management: standards and guidelines for the delivery of services in San Francisco; 2000. Available from: Project Director, Prevention Case Management Standardization and Evaluation Project, AIDS Office, San Francisco Department of Public Health, 25 Van Ness Ave. Suite 500, San Francisco, CA 94102, (415) 554-9031.

US Department of Health and Human Services, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC: US Department of Health and Human Services; 2001.

Wisconsin Division of Public Health, AIDS/HIV Program. Wisconsin Prevention with HIV-infected Persons Prevention Case Management Summary Report. Madison: Author; 2004.

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References

1. CDC. HIV Prevention Case Management: Literature Review and Current Practice; 1997.
2. CDC. HIV Prevention Case Management: Guidance; 1997.

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HIV Counseling, Testing, and Referral